Remnant Tensioning Through Pullout Sutures From the Femoral Tunnel During Anatomic Anterior Cruciate Ligament Reconstruction

ABSTRACT: Even after anterior cruciate ligament (ACL) tear, its remnant retains the vascularized synovial sheets, fibroblasts, myofibroblasts, and various mechanoreceptors within it. The aim of preserving the remnant is to retain these components during ACL reconstruction. In the recent past, there has been an increasing trend towards preserving remnants during ACL reconstruction. Although preserving remnants have physiological advantages, cyclops lesion and extension loss were among the most feared complications. Cyclops and loss of extension are due to the fallback of the remnant into the notch. Moreover, the mechanoreceptors present in the remnant are not active when the remnant is lax. These mechanoreceptors are active when the remnant is in tension. Thus, rather than merely preserving the remnant, it is essential to tension it for more physiological functions. Although there are various techniques of remnant tensioning described in the literature, these techniques require tampering of the fixation devices or an extra fixation device adding to the cost of surgery. We describe our modification of the remnant-tensioning method during anatomic ACL reconstruction. In this technique, the sutures holding the remnant are pulled out through the anatomic femoral tunnel and fixed with an interference screw along with the hamstring graft. This technique is cost-effective, reproducible, and does not require tampering with the fixation devices. Moreover, the direction of remnant pull will be the same as that of the reconstructed graft making both the graft and remnant anatomical in orientation. Suture management and visibility of the intraarticular structures during this procedure are a few downsides of this technique. The only prerequisite of this technique is a good quality remnant to hold the sutures. Technique Video Video 1 Our technique tensions the loose remnant while performing anterior cruciate ligament (ACL) reconstruction with the hamstring graft. In this video, we demonstrate anatomic single-bundle ACL reconstruction along with remnant tensioning in a 24-year-old female patient. Her diagnostic arthroscopy revealed a tear from the femoral side with good quality of remnant. A cinch knot with number 2 BioFiber tape is applied at the center of the remnant using FIRSTPASS MINI. Both tails of fiber tape are passed one by one through the substance of the remnant such that it exits from the edge of the torn end. An anatomic inside-out 8mm femoral tunnel is made through the anteromedial portal with 25 mm of socket. Two different-colored sutures are pulled through the tunnel using a beath pin, leaving loops in the far anteromedial portal. One of these suture loops is used to pull the fiber tape libs into the femoral tunnel. A tibial tunnel is made at an anatomic location. Care is taken while perforating the intraarticular cortex of the tibia. The suture loop that remained in the far anteromedial portal is pulled out through the tibial tunnel. Using this suture loop, an 8 mm hamstring graft is pulled into the femoral tunnel. The graft is tensioned from both the tibial and femoral side, a sustained pull to tape is given to tension the remnant. Aperture fixation is done with a PEEK screw on the femoral side, maintaining the pull force. After cycling the knee, tibial fixation is also performed by a PEEK interference screw.

SUBMITTER: Joshi A 

PROVIDER: S-EPMC8626705 | biostudies-literature |

REPOSITORIES: biostudies-literature